Assessment of implementation of an order protocol for end-of-life symptom management

Designing comfort care plans to treat symptoms at the end-of-life in the hospital is challenging. We evaluated the implementation of an inpatient end-of-life symptom management order (ESMO) protocol that guides the use of opiate medications and other modalities to provide palliation. Physicians and nurses caring for patients using the ESMO protocol were surveyed about care provided and their experiences. Over 342 days, 127 patients (2.6 per week) were treated using the ESMO protocol and we surveyed a nurse and/or physician for 105 (83%) patients. Most patients were comatose, obtunded/stuperous, or disoriented when the ESMO protocol was initiated and most had a life expectancy of less than 1 day. One fourth of physicians felt that the protocol was instituted too late, principally citing family unwillingness to reorient toward comfort care. Providers reported that opiates were titrated appropriately, although a minority revealed discomfort with end-of-life opiate use. Nearly all clinicians found the ESMO protocol to be valuable. A standardized protocol is a useful, but not fully sufficient, step toward improving care for dying hospitalized patients.